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<meta name="author" content="PIXINVENT">
<title>自助售货管理后台</title>
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      <h3 class="content-header-title mb-0 pull-left">申请扫呗支付</h3>
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                <li><a href="扫呗支付配置.html">扫呗支付配置</a></li>
                        <li class="active">申请扫呗支付</li>
                      
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  <div class="card">
    <div class="card-content">
      <div class="card-body">
   
        <div class="form1 form3" >
				<ul class="row">
<li class="col-sm-10 col-xs-12"><span>商户名称：</span><input type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>商户简称：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>注册名称：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>所在地区：</span>
					<ul class="row">
						<li class="col-xs-4"><select class="form-control"><option>所在省</option></select></li>
						<li class="col-xs-4"><select class="form-control"><option>所在市</option></select></li>
						<li class="col-xs-4"><select class="form-control"><option>所在县/区</option></select></li>
					</ul>
					</li>
<li class="col-sm-10 col-xs-12"><span>详细地址：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>联系人姓名：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>联系人邮箱：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>联系人电话：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>客服电话：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>结算人证件号码：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>入账银行卡开户名：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>入账银行卡卡号：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>入账银行卡开户总行：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>入账银行卡开户支行：</span><input   type="text" class="form-control"></li>
<li class="col-sm-10 col-xs-12"><span>入账银行卡正面照片：</span>
					<div class="clearfix">
						<div class="pull-left"><div class="upimgbox" style="min-width:200px;"><img src="app-assets/images/crop-pic.jpg"></div>
						<a href="#" class="file"><input type="file">选择图片</a></div>
						<div class="pull-left p-l-20"><p class="text-info">格式：jpg、png、jpeg<br>规格:210x90像素</p></div>
						</div>
					</li>
<li class="col-sm-10 col-xs-12"><span>门头照片：</span>
					<div class="clearfix">
						<div class="pull-left"><div class="upimgbox" style="min-width:200px;"><img src="app-assets/images/crop-pic.jpg"></div>
						<a href="#" class="file"><input type="file">选择图片</a></div>
						<div class="pull-left p-l-20"><p class="text-info">格式：jpg、png、jpeg<br>规格:210x90像素</p></div>
						</div>
					</li>
<li class="col-sm-10 col-xs-12"><span>内设照片：</span>
					<div class="clearfix">
						<div class="pull-left"><div class="upimgbox" style="min-width:200px;"><img src="app-assets/images/crop-pic.jpg"></div>
						<a href="#" class="file"><input type="file">选择图片</a></div>
						<div class="pull-left p-l-20"><p class="text-info">格式：jpg、png、jpeg<br>规格:210x90像素</p></div>
						</div>
					</li>
<li class="col-sm-10 col-xs-12"><span>手持身份证：</span>
					<div class="clearfix">
						<div class="pull-left"><div class="upimgbox" style="min-width:200px;"><img src="app-assets/images/crop-pic.jpg"></div>
						<a href="#" class="file"><input type="file">选择图片</a></div>
						<div class="pull-left p-l-20"><p class="text-info">格式：jpg、png、jpeg<br>规格:210x90像素</p></div>
						</div>
					</li>
<li class="col-sm-10 col-xs-12"><span>对私账户身份证正面照片：</span>
					<div class="clearfix">
						<div class="pull-left"><div class="upimgbox" style="min-width:200px;"><img src="app-assets/images/crop-pic.jpg"></div>
						<a href="#" class="file"><input type="file">选择图片</a></div>
						<div class="pull-left p-l-20"><p class="text-info">格式：jpg、png、jpeg<br>规格:210x90像素</p></div>
						</div></li>
<li class="col-sm-10 col-xs-12"><span>对私账户身份证反面照片：</span>
					
					<div class="clearfix">
						<div class="pull-left"><div class="upimgbox" style="min-width:200px;"><img src="app-assets/images/crop-pic.jpg"></div>
						<a href="#" class="file"><input type="file">选择图片</a></div>
						<div class="pull-left p-l-20"><p class="text-info">格式：jpg、png、jpeg<br>规格:210x90像素</p></div>
						</div>
					</li>
					
					
					
		<li class="col-sm-10 col-xs-12"><input type="submit" class="btn btn-primary" value="确认保存"></li>
	
					</ul>
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